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Pregnancy and diabetes

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Pregnancy is associated with changes in insulin sensitivity which may lead to changes in plasma glucose levels. For women with known diabetes or for women who develop diabetes during the pregnancy, these changes can put outcomes at risk. This guideline deals with the means of identifying women for whom such problems are new, and helping them, as well as women already known to have diabetes, to achieve the desired outcome of a healthy mother and baby.
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Global Guideline
Pregnancy
and diabetes
Pregnancy_EN2.indd 1
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The mission of the International Diabetes Federation is to promote
diabetes care, prevention and a cure worldwide
© International Diabetes Federation, 2009
All rights reserved. No part of this publication may be reproduced or
transmitted in any form or by any means without the written prior
permission of the International Diabetes Federation (IDF).
Requests to reproduce or translate IDF publications should be addressed
to IDF Communications, Chaussée de la Hulpe 166, B-1170 Brussels,
Belgium, by e-mail to communications@idf.org, or by fax to +32-2-5385114.
This guideline was supported by an unrestricted educational grant from Eli Lilly
and Company. This company had no involvement in the writing, review and
approval of the manuscript.
Citation
IDF Clinical Guidelines Task Force.
Global Guideline on Pregnancy and Diabetes.
Brussels: International Diabetes Federation, 2009.
This and other IDF publications are available from:
International Diabetes Federation
Chaussée de la Hulpe 166
B-1170 Brussels
Belgium
Tel: +32-2-5385511
Fax: +32-2-5385114
www.idf.org
Pregnancy_EN2.indd 2
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Global Guideline on Pregnancy and Diabetes
Members of the
Members of the
Writing Group
Expert Review
Nam Han Cho (South Korea)
Committee
Stephen Colagiuri (Australia)
Edward Coetzee (South Africa)
Lois Jovanovic (USA)
Donald Coustan (USA)
Robert Moses (Australia) (Chair)
Moshe Hod (Israel)
Maria Inês Schmidt (Brazil)
Dorte Jensen (Denmark)
Terence Lao (People’s Republic of China)
Medical Writer
Gloria López-Stewart (Chile)
Elizabeth Home (UK)
Sara Meltzer (Canada)
Ingvars Rasa (Latvia)
Veerasamy Seshiah (India)
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Global Guideline on Pregnancy and Diabetes
Contents
1. Introduction ....................................................................................................4

6. Recommendations for Standard Care ..................18

Pre-pregnancy counselling .............................................................. 18
2. Gestational diabetes mellitus (GDM) ........................5

At first prenatal visit ............................................................................... 19

2.1 Defining the condition ................................................................. 5

Frequency of subsequent visits ............................................... 20

2.2 Diagnosis of GDM .............................................................................. 5


Ongoing management of diabetes

2.3 Rationale for treating GDM ................................................. 5
during pregnancy .......................................................................................... 20

Management of gestational diabetes ............................... 21
3. Before pregnancy .....................................................................................6

3.1 General issues for different groups

After delivery .................................................................................................... 22
of women

Breastfeeding ...................................................................................................... 22
........................................................................................................ 6

3.2 Review of medications

Follow-up within 6 weeks ............................................................... 22
................................................................. 7

3.3 Pre-conception glycaemic control .............................. 8
7. Implementation .....................................................................................23
4. During pregnancy ....................................................................................9

4.1 Testing of all or some women for GDM
8. Evaluation .......................................................................................................23
............ 9

4.2 Testing for GDM – a two-stage or
9. References .....................................................................................................24
one-stage procedure? ................................................................. 10

4.3 Management during pregnancy .................................... 10
5. After pregnancy ......................................................................................16

5.1 Breastfeeding .......................................................................................... 16

5.2 Follow-up of GDM ........................................................................ 16

5.3 Prevention of type 2 diabetes in women
who developed GDM ................................................................ 17
3
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Global Guideline on Pregnancy and Diabetes
1. Introduction
final revision which has taken into consideration comments
received from this wide consultation.
Pregnancy is associated with changes in insulin sensitivity
which may lead to changes in plasma glucose levels. For
The aim was to draw up a set of recommendations for
women with known diabetes or for women who develop
Standard Care as envisaged in the 2005 Global Guideline
diabetes during the pregnancy, these changes can put
[1] and which represents current best practice. It is ac-
outcomes at risk. This guideline deals with the means of
knowledged that due to limited human and material re-
identifying women for whom such problems are new, and
sources, many countries or health systems wil not be able
helping them, as well as women already known to have
to implement al of the recommendations in this Guideline.
diabetes, to achieve the desired outcome of a healthy
The Recommendations are presented together towards
mother and baby.
the end of the document (section 6). The topics covered
in this Guideline have in general been presented in the
Within the IDF Global Guideline for Type 2 Diabetes of
order encountered before, during, and after pregnancy,
2005 [1] there was a section on pregnancy, but this did not
except that gestational diabetes is introduced first.
address type 1 diabetes and did not consider the wider
issues surrounding gestational diabetes mellitus (GDM)
and prevention of diabetes. The current guideline includes
these additional topics, and attempts to present some of
the evidence bearing on areas of controversy.
Since 2005 an evidence-based guideline on diabetes in
pregnancy has been published in the UK [2], the Canadian
evidence-based diabetes guideline (including pregnancy) has
been revised [3], and there have been further deliberations
on the implications of the Hyperglycemia and Adverse
Pregnancy Outcome (HAPO) study [4]. In preparing the
current guideline, a non-formal evidence review was circu-
lated to, and discussed by, a small Writing Group in March
2009, then redrafted before circulation to an Expert Review
Committee. The revised draft was referred to IDF member
organizations for comments. This document represents the
4
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Global Guideline on Pregnancy and Diabetes
2. Gestational diabetes may wel be addressed by recommendations arising from
mellitus (GDM)
the International Association of Diabetes in Pregnancy
Study Groups (IADPSG), a working group analysing the
2.1 Defining the condition
results of the HAPO study. Any recommendations from this
The widely accepted definition is that given by the
group wil then need to be considered by relevant national
American Diabetes Association (ADA) ‘…any degree of
bodies and incorporated into the local health service ar-
glucose intolerance with onset or first recognition dur-
rangements. This process wil take some time. Other than
ing pregnancy’ [5]. The definition is applicable even if ‘the
by chance, it is not clear if any diagnostic criteria of GDM
condition persists after pregnancy’. ‘It does not exclude the
based exclusively on pregnancy outcomes wil be applicable
possibility that unrecognized glucose intolerance may have
to the other two elements of risk.
antedated or begun concomitantly with the pregnancy.’
The widespread acceptance of this definition is in no small
2.3 Rationale for treating GDM
part due to the fact that it does not mention any specific
It is generally acknowledged that women with GDM are
diagnostic criteria.
at increased risk of adverse pregnancy outcomes, par-
ticularly relating to perinatal mortality and morbidity. It
Any definition of GDM has to take into account three
is also general y acknowledged that treatment of women
elements of risk – of perinatal morbidity and mortality in
with GDM, by whatever means, can reduce the risk of
the current pregnancy, of the mother developing type 2 dia-
these problems. In the developed world an increased
betes, and of intra-uterine programming of the developing
perinatal mortality rate is unlikely but can stil be dem-
fetus with subsequent expression of disorders in later life.
onstrated in a sufficiently large series [12]. However, in
settings where obstetric care does not uniformly reach
2.2 Diagnosis of GDM
modern quality standards, perinatal mortality is stil an
There is a continuum of risk for maternal glucose levels and,
important issue [13].
at least, adverse pregnancy outcomes [6-11]. Currently there
is a lack of international consensus regarding the diagnostic
Perinatal morbidity is an ongoing concern. Macrosomic or
criteria for GDM. In most parts of the world the diagnostic
large-for-gestational-age (LGA) infants are still common,
criteria are based on either the 100 gram 3-hour test as
and can be considered a surrogate marker for at least
commonly used in the USA or the 75 gram 2-hour World
some of the effects of intra-uterine programming.
Health Organization (WHO) test. Many national bodies
have derived their own criteria based on local experience
and their healthcare delivery systems. This lack of consensus
5
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Global Guideline on Pregnancy and Diabetes
An earlier prospective control ed trial demonstrated that
3. Before pregnancy
‘tight’ control, with a high rate of insulin use, improved peri-
3.1 General issues for different groups of women
natal outcomes [14]. Later, a prospective non-randomized
Al women contemplating a pregnancy should ideal y have
intervention study demonstrated for women with GDM that
pre-conception advice from a healthcare professional.
intensive control (versus conventional control) improved
This is particularly important for women who currently
perinatal outcomes to a level that was comparable to a
have diabetes or intermediate degrees of hyperglycaemia
group without GDM [15]. The hazards of a late diagnosis
(impaired glucose tolerance – IGT, or impaired fasting
of GDM, and therefore ef ectively no treatment, have been
glucose − IFG), or have experienced GDM in a previ-
outlined [16]. The Australian Carbohydrate Intolerance Study
ous pregnancy.
in Pregnancy (ACHOIS), a blinded randomized trial including
1000 women, designed to examine whether the treatment
Women with GDM in a previous pregnancy should have
of women with GDM would reduce perinatal complications,
had their glycaemic status clarified in the postpartum pe-
found a significant reduction in serious perinatal complica-
riod. The probability of developing GDM in a subsequent
tions in the treated group [17]. Recently the results of the
pregnancy is of the order of 30% to 50% [25]. If more
Maternal-Fetal Medicine Unit (MFMU) Network study have
than a year has passed since the postpartum assessment,
become available. Treating women with designated ‘mild’ GDM
then these women should have an oral glucose tolerance
lowered the risk for many adverse pregnancy outcomes [18].
test (OGTT) prior to conception or at least in the first
trimester. If the glycaemic status is then normal, the OGTT
Limited observational studies in humans strongly suggest
should be repeated at around 26 to 28 weeks, or at an
that any pregnancy complicated by hyperglycaemia confers
earlier time if clinically indicated. These indications may
a risk to the offspring of developing type 2 diabetes [19-24],
include, but are not limited to, the development of glycos-
and that improving maternal glycaemic control may reduce
uria, increased amniotic fluid or a suspicion of increased
this risk. However, the long follow-up necessary makes
fetal size. Women with previous GDM who are shown to
it unlikely that any randomized control ed trial (RCT)
have normal glucose tolerance postpartum, and women
evidence will be forthcoming in the foreseeable future.
with previous GDM who experience a recurrence, do not
appear to be at increased risk of first trimester malforma-
tions other than the risks associated with obesity.
6
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Global Guideline on Pregnancy and Diabetes
Women already known to have diabetes (sometimes
There are theoretical problems potential y associated with
called ‘pre-gestational diabetes’ in this context) need to
the use of ARBs in pregnancy, but only very limited data on
consider how the effects of their pregnancy may impact
this topic. Calcium channel blockers have the potential to
on the diabetes, and on any of their diabetes-associated
cause fetal hypoxia and should be used cautiously if at all.
problems. Hypoglycaemia is more likely to occur in preg-
nancy, especial y in the first trimester, as a greater effort is
For statins, congenital malformations have been reported
made to attain and maintain glycaemic control. A variable
and there is concern that decreased cholesterol synthesis
dietary intake associated with morning sickness may also
may affect fetal development [29], but evidence on use in
increase this tendency towards hypoglycaemia. Women
pregnancy is very limited. Data on the use of fibrates and
with established diabetic complications, such as retinopa-
niacin are also limited.
thy or nephropathy, may experience a worsening during
the pregnancy. These aspects should ideally be assessed
These medications need to be stopped as part of pre-
prior to any pregnancy and/or at such intervals during the
conception planning or as soon as a pregnancy is recog-
pregnancy as clinically indicated.
nized. Sufficient blood pressure control should be secured
by using methyldopa or labetalol.
3.2 Review of medications
Women with diabetes or previous GDM may be taking
In common with other women during pregnancy, women
medications contra-indicated in pregnancy. These include,
with diabetes need to ensure there is an adequate intake
but are not limited to, angiotensin converting enzyme
of folic acid.
(ACE) inhibitors, angiotensin-II receptor blockers (ARBs),
calcium channel blockers and lipid lowering agents.
Women with type 2 diabetes who are taking either met-
formin and/or glyburide (glibenclamide) need to have the
In a large cohort study of pregnancy which excluded women
potential advantages and disadvantages of these medica-
with diabetes, first-trimester exposure to ACE inhibitors
tions outlined and to continue with them if it is in their
was associated with an increased risk of major congenital
best interests to do so.
malformations compared to the use of other anti-hyperten-
sive agents [26]. If ACE inhibitors were being used to treat
diabetic nephropathy prior to pregnancy, then a significant
deterioration in proteinuria can be anticipated during the
course of the pregnancy fol owing discontinuation [27,28].
This aspect wil need to be considered when offering advice.
7
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Global Guideline on Pregnancy and Diabetes
3.3 Pre-conception glycaemic control
before meals and <8.5 mmol/l (<153 mg/dl) after meals.
Women with diabetes have increased risk of an early
Women with an elevated HbA value above 8.0% should
1c
miscarriage and are at increased risk of having a baby
be discouraged from becoming pregnant until their control
with malformations. Both of these risks are associated
can be improved. There are currently no equivalent data
with less than optimal glycaemic control around the time
about glucose levels.
of conception and in the first trimester. The extent of
the risk is difficult to quantify, but risks appear to be ap-
Women with diabetes without pre-conception planning, or
proximately equivalent for women with type 1 diabetes
with an unexpected pregnancy, should have their glycaemic
and type 2 diabetes. Women with type 2 diabetes appear
control assessed as soon as practical, and advice on risk
to have a lesser uptake of pre-conception counsel ing [30].
should be offered on the basis of this result.
The increased rate of spontaneous miscarriages appears
to be low when the HbA is modestly raised, and higher
1c
with increasingly poor glycaemic control [31-33]. The
risks increase rapidly with higher levels of HbA . The
1c
same pattern is also found with respect to the rate of
fetal malformations [34-36]. Women who improve their
glycaemic control before conception have a reduced rate
of fetal malformation [37]. There appears to be no level of
glycaemic control below which no increased risk has been
observed [38]. Women with diabetes should be encour-
aged to obtain the best possible glycaemic control before
conception, aiming for, in the absence of confounding vari-
ables that may alter the accuracy of the assay, an HbA
1c
<6.5% (or <7.0% if on insulin). Some consensus opinions
advocate a lower value and this is reasonable if it can be
safely achieved and maintained. In line with a recent analysis
[39], an HbA <6.5% might equate with self-monitored
1c
capillary plasma glucose values <6.5 mmol/l (<117 mg/dl)
8
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